Summary of Privacy Practices

Date of Last Revision: March 21, 2003   |   Effective Date: April 1, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices. Upon request, we will provide you with our full-length Notice of Privacy Practices.

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.

Here are a few examples (for more detail please request a copy of our Notice of Privacy Practices):

• For medical treatment
• To obtain payment for our services
• In emergency situations
• For appointment and patient recall reminders and/or to notify you your optical goods are ready for you to pick up
• For research
• To avert a serious threat to health or safety
• For worker's compensation programs
• To run our Practice more efficiently and ensure all our patients receive quality care

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our Administrator. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You have certain rights regarding the information we maintain about you. These rights include:

• The right to inspect and copy
• The right to amend
• The right to accounting of disclosures
• The right to request restrictions
• The right to a paper copy of this notice
• The right to request confidential communications

For more information about these rights please request our detailed Notice of Privacy Practices.